With the White House putting cancer prevention and early treatment squarely in the sights of its renewed Cancer Moonshot initiative, recent University of Michigan (U-M) research offers insights that policymakers could use to ensure more cancers are diagnosed earlier and reduce inequalities.

The research relates to the part of the Affordable Care Act that makes certain cancer screenings and other preventive care available to patients at no cost. That provision was specifically designed to keep financial barriers like co-pays and insurance plan deductibles from getting in the way of detecting early signs of trouble. But what happens when the results of the free initial screening are abnormal, and more scans or tests must be done to see if it’s really cancer?

The frequency and potential cost of this side of cancer screening is the focus of recent studies from U-M researchers and their colleagues, who measured costs that patients face for necessary follow-up tests after getting free screening for colon, cervical, lung, or breast cancer.

“For those who have an abnormal initial cancer screening test, it makes no sense to put a barrier in place for that individual to complete the diagnostic process,” says A. Mark Fendrick, MD, who helped lead the new studies and directs U-M’s Center for Value-Based Insurance Design. “The main goal of cancer screening is to detect those people who could benefit from early detection.”

He and the teams behind the recent studies aimed to inform policies that might remove financial barriers to increase the number of people—especially women and members of underserved populations—who will follow up on abnormal test results. Failure to complete the screening process could lead to cancer progressing, potentially leading to worse patient outcomes and high medical costs.

Colorectal Cancer Screening

Many average-risk adults opt for stool-based screening tests, such as those that look for blood or DNA markers of colorectal cancer, because they take less time and preparation than a screening colonoscopy, and they can be done at home. These options, as well as screening colonoscopy, are available without out-of-pocket costs. Clinical guidelines say that those who test positive on a stool test need a follow-up colonoscopy.

The JAMA Network Open study examined how often patients are charged, and what patients actually paid out of their own pockets, for such follow-up colonoscopies. It involves data from nearly 88,000 people with private insurance or Medicare coverage who had a stool-based test.

In all, 16% of them went on to have a colonoscopy. During that colonoscopy, nearly 60% of the group had at least one polyp removed, because it might be cancerous or precancerous.

More than half of the privately insured patients and 78% of the Medicare participants had to pay something out-of-pocket for their follow-up colonoscopy. It averaged around $100, no matter what kind of insurance the patients had. Those who had polyps removed paid more than those who didn’t.

The Preventive Medicine study, based on a simulation using patient data, suggests that follow-up colonoscopies after positive stool tests could save up to four times as many years of life saved from colorectal cancer, and prevent twice as many deaths, when compared with the same number of people who have a colonoscopy as their initial colorectal screening test. This is because those having a colonoscopy after an abnormal stool test are at higher risk for actually having cancer than those having a primary screening colonoscopy.

The studies helped inform a new federal rule requiring private health insurance plans to provide coverage for follow-up colonoscopies without cost to the patient beginning on or after May 31, 2022.

“This is an extremely important policy that could increase screening uptake, enhance equity and ultimately save lives, which are stated goals of the Cancer Moonshot. The removal of a cost barrier starting this spring could help hundreds of thousands more people avoid the dilemma of having to decide if they can afford to follow up on their initial positive colorectal screening test,” says Fendrick. 

“However, the new rule does not apply to Medicare beneficiaries, and it does not apply to other cancers for which screening tests are fully covered for some or all individuals: breast, lung, and cervical cancer.”